Ideas, Evidence & Intuitions: what we’re thinking about

Here at IMAGO, we are launching a blog series on topics from articles, papers, podcasts, videos, books, movies, and any other mediums that we find interesting and important to our work and inform our perspectives. Here is the first periodic roundup!

1. Local systems and contexts are vital to healthcare outcomes, and it is unmistakably important to take time and effort to understand them.This recent article on “parachuting doctors” in poor countries critiques a set of ethical guidelines developed by U.S. physicians for medical volunteers, which were written without anyone from the so-called developing world. It delves into how failing to understand context can do harm, and concludes that instead of “parachuting in” (and out again), medical professionals can support healthcare systems much more effectively by consulting local hospitals and clinicians, understanding what tests and technology are available for follow-up, and the cultural contexts in which they operate. This takes time and effort.

The article also reminds me of what anthropologist and physician Paul Farmer has said repeatedly about the many overseas contexts in which he’s worked – his diary entry from October 2014 after a trip to Liberia to help with the Ebola crisis details exactly how ready-made, short-term solutions do more harm than a comprehensive model that deals with an entire healthcare system. It also makes clear just how much Farmer studies the details of local systems – seamlessly blending his thinking about action against Ebola with implications of support based on availability of funding, paved roads and electricity:

I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.

If such things were thin on the ground in Monrovia and Freetown, they were all but absent in rural regions. Zwedru is the capital of Grand Gedeh County in south-eastern Liberia, a region mostly covered by rainforest. Flying from Monrovia to Zwedru reminds you how vast and green – and rainy – much of the country is, especially in September. Outside the capital, paved roads are as scarce as electricity: in 2013, it was estimated that less than 1 per cent of Liberia was electrified. As Sirleaf recently pointed out, the Dallas Cowboys football stadium consumes more energy each year than the whole of Liberia. It is very difficult to take care of critically ill patients in the dark; fluid resuscitation depends on being able to place and replace intravenous lines.

It’s notable that Farmer makes the same diagnosis for the American community-based healthcare system and the issues it has in treating chronic disease among the poor and elderly: “the big idea that I would give to graduates of medical schools and nursing schools is that we can only have real impact, and the best impact, when we work in teams. And those teams have to reach from hospitals and clinics, to communities.” Wherever you look, it seems, local contexts are important and it is to the detriment of development outcomes when they are overlooked.

2. Operations, operations, operations! From effective altruism careers blog, 80,000 Hours – “Operations looks like the highest-impact role for many people in the effective altruism and existential risk communities right now, rather than the roles that might first come to mind, such as research, outreach or earning to give.” Providing support to streamlining organizational operations and systems is a big focus of our work at IMAGO, and though we are not all “effective altruists,” per se, the post lays out many details about exactly why operations are so important in the development sector, and how the different functionalities of operations roles can matter immensely for impact. On a more philosophical note, Larry Temkins discusses why Peter Singer’s analogy of saving a drowning child as the basis for his philosophy of effective altruism may not exactly capture how country contexts and systems work.

3. New findings on sponsorship programs and the gender gap. Experimental research findings from HBS demonstrate that “companies increasingly provide sponsors to help women get ahead. But certain aspects of sponsorship programs can hinder women instead, according to experimental research by Nancy R. Baldiga and Katherine B. Coffman.” The research is only based on some aspects of what sponsorship programs entail (given the experimental simulation), but provides valuable evidence on relative interests, and food for thought on the design of better sponsorship programs based on how they can provide support in an inherently relative context (the gender gap is about the difference between men and women, not about levels).

In one round of the experiment, participants could opt for a guaranteed payment of 50 cents per problem solved, or they could compete for higher stakes. Those who chose to compete received a significantly higher payout (ranging from $1 to $3 per problem) if they scored in the top 25 percent of the problem solvers, but received nothing if they did not. As the researchers predicted, more men than women chose the competition over the guaranteed payment.

The subsequent round introduced the element of sponsorship. In each session, three participants were randomly chosen as “sponsors” who would receive 25 cents each time a “protégé” correctly solved a problem—but only if their protégé scored in the top quartile and decided to choose the high-stakes competition over the lesser guaranteed payment.

Significantly, the protégés were told that they had sponsors before choosing whether to take the guaranteed 50 cents per solved problem or whether to compete for more money. The goal of the researchers: To find out whether participants were more likely to compete if someone were sponsoring them.

The research revealed that sponsorship definitely increased the likelihood that participants would choose a high-stakes competition over a non-competitive guaranteed payment—but this proved true only among male participants. And in terms of the choice to compete, sponsorship had the most dramatic effect among the men who performed the worst on the math problem exercise.

4. Women at work and a discussion of how many different perspectives there are around the world. I have been listening to Women’s Work – a podcast celebrating “creative women who do interesting work,” and Rough Translation (by NPR) – a show about different perspectives that we may not have thought of from our own bubbles – “familiar conversations in unfamiliar territories.” Some favorite episodes so far include Brazil in Black and White, The Refugee’s Dating Coach, and Om Alone in India.